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3040 N. University Ave., Suite 2 Decatur, IL 62526
217-872-1700
Decatur Psychological Associates, P.C.
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Release of Information Form
Home
Staff
Fee Schedule
Forms
Registration & Consent Forms
Release of Information Form
Registration & Consent Forms
1
Registration
2
Financial Policy
3
Insurance Information
4
Consents
5
Contact Information Form
6
HIPPA Privacy Policy
7
REGISTRATION
Today's Date
*
MM slash DD slash YYYY
Name
*
First
Last
Preferred Name
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
*
MM slash DD slash YYYY
Home Phone
Cell Phone
*
Work Phone
Appointment reminder calls?
*
Home
Cell
Work
I prefer to be reminded by email
Email
*
Enter Email
Confirm Email
Are you employed?
*
Yes
No
Name of Employer
Occupation
Is the patient under the age of 18?
*
Yes
No
Legal Guardian's Name
*
First
Last
Relationship
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
*
Work Phone
Date of Birth
*
MM slash DD slash YYYY
Do you have a primary care physician
*
Yes
No
Primary Care Physician
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
May we contact your Physician if necessary?
*
Yes
No
Please list all medications you are currently taking
Please list any allergies
FINANCIAL POLICY
Patients are responsible for providing all demographic and insurance information at the time of service. Billing your insurance company is a courtesy and all balances not covered by insurance are your responsibility
All charges for co-pay, co-insurance and self-pay are due on the day of the appointment. Payment may be made using cash, check or credit/debit card. Until your insurance and deductible/co-pay amount can be verified, you are responsible for the total payment of each office visit.
You are responsible to check with your insurance company to verify coverage and verify provider participation.
There is a $20 fee for checks returned for insufficient funds.
If your account is past due with no payment for 90 days, it may be turned over to a collection agency. You would be responsible for your balance plus collection fees.
If an appointment is made and is not cancelled 24 hours prior to the appointment time, a $50 No Show charge will be applied to your account.
Name
*
First
Last
Signature of Patient (or Guardian)
*
Initials
*
Date
*
MM slash DD slash YYYY
INSURANCE INFORMATION
Method of Payment
*
Self Pay
EAP
Insurance
Other
Name of Insurance Company
*
Insurance ID Number
*
Group Name and Number
*
Phone Number of Company
*
Is Preauthorization required?
*
Yes
No
Is Physician Referral required?
*
Yes
No
Is the patient the insured member?
*
Yes
No
Name
First
Last
Relationship
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Cell Phone
*
Home Phone
Date of Birth
*
MM slash DD slash YYYY
Employer
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Consent
*
I DO give my permission for Decatur Psychological Associates, to bill my insurance or Employee Assistance Program for services rendered.
I DO NOT give my permission for Decatur Psychological Associates, P.C., to bill my insurance or Employees Assistance Program for services rendered.
Name
*
First
Last
Signature
*
Initials
*
Today's Date
*
MM slash DD slash YYYY
CONSENTS
Name
*
First
Last
Birth Date
*
MM slash DD slash YYYY
CONSENT OF TREATMENT:
I authorize and consent to the performance of psychiatric treatment and/or testing considered necessary or advisable by staff associated with Decatur Psychological Associates, P.C.
ASSIGNMENT OF BENEFITS:
I hereby authorize direct payment of mental health benefits to Decatur Psychological Associates, P.C. for services rendered. I understand that I am financially responsible for any balance not covered by my insurance. I also understand that if this bill goes to collection and/or an attorney, I am fully responsible for all reasonable costs for collection and/or attorney fees that are incurred, as well as court costs.
RELEASE OF INFORMATION:
I authorize Decatur Psychological Associates, P.C. to release information including but not limited to; Medical History, Diagnosis, Mental Health Assessments and Progress Notesto any physician that may have referred me to this practiceor to any physician that I may be referred to by this practice.
Signature of Patient (or Guardian)
*
Initials
*
Date
*
MM slash DD slash YYYY
CONSENT FOR USE OF PROTECTED HEALTH INFORMTION (PHI) FOR TREATMENT, AND PAYMENT AND HEALTHCARE OPERATIONS:
My “PHI” means health information, including my demographic information, collected from me and created or received by my health care provider, another health care provider, a health plan, my employer or a health care clearinghouse. This “PHI” relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I consent to the use of disclosure of my “PHI” for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations.
I understand that diagnosis or treatment of me may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my “PHI” is used or disclosed to carry out treatment, payment or healthcare operations of the practice. My Provider is not required to agree to the restrictions that I may request. However, if she/he agrees to a restriction that I request, the restriction is binding.
I have the right to revoke this consent, in writing, at any time, except to the extent that my provider has taken action in reliance on this consent. I understand I have the right to review my provider’s Notice of Privacy Practices prior to signing this document.
Signature of Patient (or Guardian)
*
Initials
*
Date
*
MM slash DD slash YYYY
CONTACT INFORMATION
I authorize Decatur Psychological Associates, P.C. to communicate with the following people (for example: parents, guardians, spouses, partners, friends) to confirm insurance or appointment information.
*
Name
Phone
Relationship
Emergency Contact (yes/no)
I further agree that a photocopy of this agreement shall be as valid as the original.
Signature of Patient (or Guardian)
*
Initials
*
Date
*
MM slash DD slash YYYY
Signature of Patient (if age 12-17)
Initials
Date
MM slash DD slash YYYY
HIPAA NOTICE OF PRIVACY AND SECURITY POLICY
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Our Company respects your privacy and understands that your personal health information is sensitive. According to the Health Insurance Portability and Accountability Act of 1996 (HIPPA), we cannot disclose your “protected health information” to others unless we have your permission –or unless the law authorizes or requires us to do so.
The Health Information Technology for Economic and Clinical Health (HITECH) Act also requires us to notify you when the security or privacy of your health information is breached. Depending on the type of breach and how many individuals are affected, this many also involve notifying the media and/or government enforcement agencies, and keeping a log of all breach incidents.
What is Protected Health Information?
Protected health information (PHI) is individually identifiable information, maintained or transmitted through any medium. It relates to an individual’s past, present, or future physical or mental health or healthcare. Health information is individually identifiable if it either identifies you or another person by name and must be protected. Other identifiable information that must be protected includes address, Social Security number, dates of service, telephone number, e-mail address or vehicle identification number.
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment:
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment:
Your protected health information will be used, as needed, to obtain payment for your health care services.
Healthcare Operation:
We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of students, licensing, and conducting or arranging for other business activities. We may also call you by name in the waiting room when your physician or therapist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal proceedings, law enforcement, coroners, funeral directors, and organ donation, research, criminal activity, military activity and national security, Workers’ Compensation, Inmates. Required Uses and Disclosures, for pre-employment physicals and to determine fitness for duty for the employee’s job, for requests for accommodation under the Americans with Disabilities Act (ADA), to administer leave under the Family and Medical Leave Act (FMLA) (where applicable) , or to comply with OSHA, MSHA and similar state laws. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164-500.
Designated Record Set (DRS)
Designated Record Sets (DRSs) become the repositories of protected health information that patients can access, amend, or restrict access to in exercising their individual rights. DRSs are the hard copy files we keep as well as electronic data sets.
Other Permitted and Required Uses and Disclosures
will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Your rights:
Following is a statement of your rights to your protected health information.
You have the right to inspect and copy your protected health information.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonably anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You must make this request in writing, and we may deny your request for certain information.
You have the right to request a restriction of your protected health information.
This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members of friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare professional.
You have the right to receive confidential communications from us by alternative means or at an alternative location. You have a right to obtain a paper copy of this notice from us,
upon request, even if you have agreed to accept this notice alternatively, i.e., electronically.
You may have the right to have your physician amend your protected health information.
If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserved the right to change the terms of this notice. You then have the right to object or withdraw as provided in this notice.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint.
We will not retaliate against you for filing a complaint.
This notice became effective on April 14, 2003.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our office
Consent
*
I acknowledge that I have received a copy of the HIPAA NOTICE OF PRIVACY AND SECURITY POLICY.
A copy of the HIPPA Notice of Privacy and Security Policy can be downloaded and/or printed from this website.
Name
*
First
Last
Signature of Patient (or Guardian)
*
Initials
*
Date
*
MM slash DD slash YYYY
RELEASE OF RECORDS
This form is optional
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Hereby REQUEST and AUTHORIZE Decatur Psychological Associates, P.C. to release/obtain the following information pertaining to my Substance Abuse and/or Mental Illness:
Check all that Apply
Select All
Medical History
Diagnosis & Prognosis
Social History
Psychiatric History
Psychological History
Treatment Plan
Summary
Laboratory Results
X-Ray Reports
Operative Notes
Progress Reports
Financial History
Substance Use History
Legal History
Mental Health Assessment
Personal History
Educational History
Other (Specify Below)
Other (please specifiy)
Release to / obtain from:
Name of Physician, Health Care Facility, Agency Etc.
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
Fax
The above information for the following period of time shall be released:
MM slash DD slash YYYY
From
To
MM slash DD slash YYYY
To
This information is being disclosed from records whose confidentiality is protected by one of the following state or federal laws. State law and federal regulation (42CFR part 2) and mental health and developmental disabilities confidentiality act (ILL. Rev Sate 1991. ch91 1/2 Par 801 ct seq.) which prohibits the redisclosure of any general authorization for the release of medical or other information is not sufficient for this purpose. I understand that I have the right to inspect and receive copy of the information that is disclosed.I understand that I can revoke this consent in writing at any time except as to disclosures already made. Unless revoked, this consent to release will expire on year from the date signed on...
Today's Date
MM slash DD slash YYYY
This is a continuing disclosure which covers the entire treatment episode and until all claims are filed and processed.
I attest to the Identity of Signatory (is) below:
Guardian Signature
Initials
Date
MM slash DD slash YYYY
Patient Signature
If the Patient is 13 years or older they MUST also sign the consent
Initials
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